Healthcare Provider Details

I. General information

NPI: 1588139125
Provider Name (Legal Business Name): ANTWON E ELIJAH I QMHS/CMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 02/13/2026
Certification Date: 02/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 TROY ST
DAYTON OH
45404-1852
US

IV. Provider business mailing address

813 TROY ST
DAYTON OH
45404-1852
US

V. Phone/Fax

Practice location:
  • Phone: 937-982-1500
  • Fax:
Mailing address:
  • Phone: 937-982-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberS.1800373-TRNE
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: